Healthcare Provider Details

I. General information

NPI: 1447678131
Provider Name (Legal Business Name): STEVEN FISHBURN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2014
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MSC 10 6000 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

IV. Provider business mailing address

MSC 10 6000 1 UNIVERSITY OF NEW MEXICO
ALBUQUERQUE NM
87131-0001
US

V. Phone/Fax

Practice location:
  • Phone: 505-272-2610
  • Fax: 505-272-1300
Mailing address:
  • Phone: 505-272-2610
  • Fax: 505-272-1300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD2016-0830
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: